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HOW TO SUBMIT A CLAIM – HOSPITAL & MEDICAL
IMPORTANT
• All claims must be reported within 30 days of occurrence.
• Written proof of claim must be submitted within 90 days of occurrence.
• You are responsible for any fees charged for completing this form or issuing supporting documentation.
TO SUBMIT YOUR CLAIM:
STEP 1
STEP 2
STEP 3
STEP 4
STEP 5
Gather all your claim documentation
Complete and sign the claim form
Complete any other necessary forms
Complete the checklist below
Mail all documentation to TIC
CHECKLIST
Do you have:
❑
❑
❑
❑
The fully completed claim form, signed and dated?
Incomplete claim forms will be returned to you and this will delay the processing of your claim submission.
All original receipts?
Photocopies will not be accepted.
For Multi-trip/Annual plans: Proof of departure?
For example: boarding pass; plane ticket; copy of stamped passport; if driving, credit or debit card statement showing
purchases before leaving province and after arriving at destination.
Provincial forms, if required?
Click the applicable hyperlink below.
Province
Form(s)
Alberta
Insurance claim consent and authorization
British Columbia
Schedule A
Out-of-Country Claim Form
Saskatchewan
Schedule A and Schedule B
Ontario
OHIP Authorization and Release Form
Quebec
Application for Reimbursement
Power of Attorney
Newfoundland and Labrador
Out-of-Province Claim Form
Application for Newfoundland Hospital Insurance Benefits
Nova Scotia, PEI, New Brunswick, Manitoba, all Territories No provincial forms required
❑
A copy of all documents for your records?
Print Form
Send your completed forms
and original receipts to:
To check your claim status,
please call:
TIC Claims Department
2100 – 250 Yonge Street
Toronto, Ontario M5B 2L7
Toll-free Canada/USA:
Canada/USA 11-800800-869869-6747
6747
Collect worldwide: 416-340-8809
416-340-8809.
E-mail: [email protected]
7T003CF-0313_rev
Underwritten by Co-operators Life Insurance Company. Property risks underwritten by The Sovereign General Insurance Company.
CLAIM FORM – HOSPITAL & MEDICAL
SECTION 1: PRIVACY AND DECLARATION
TIC Travel Insurance Coordinators Privacy Statement
TIC is committed to protecting the privacy, confidentiality, accuracy and security of the personal information that it collects, uses, retains and
discloses in the course of conducting business.
At TIC, we recognize and respect the importance of privacy. When you enrol for insurance coverage or submit a claim, we establish a confidential file
and collect, use and disclose your personal information for the purposes of issuing, administering, adjudicating and/or servicing your insurance.
You may access and correct, if needed, the personal information in your file by sending us a request in writing.
We limit access to your personal information to our staff and other persons we have authorized who have a need to know it to perform their duties.
Our systems and procedures are designed to prevent the loss, misuse, unauthorized access, disclosure, alteration, or destruction of your information.
Our commitment to security extends to the contracts and agreements we sign with external suppliers and service providers. We may store or process
your personal information in Canada, the United States or other countries for processing, storage, analysis or disaster recovery and, under applicable
law, governments, courts, law enforcement or regulatory agencies, may, by lawful order, obtain disclosure of your personal information. You can
find more details about TIC’s privacy policy at www.travelinsurance.ca. If you have any questions regarding our privacy practices, please contact
the Privacy Officer at :
TIC Travel Insurance Coordinators Ltd
2100 – 250 Yonge Street,
Toronto, ON M5B 2L7
Telephone: 416-340-0100
E-Mail: [email protected]
If you do not agree with our use and disclosure of your information in connection with your application and servicing any policy that we issue, we will
not be able to offer you the insurance product you are interested in, service your insurance or adjudicate your claim.
I have read and understood the privacy statement and I consent to the collection, use, retention and disclosure of my personal information or those of my
dependants for the purposes stated above. I understand that I may revoke my consent at any time in writing and acknowledge that should I do so, my claim
may not be adjudicated.
I hereby assign to TIC any benefits obtainable from other sources for losses covered under this policy. I authorize and direct these sources to release payments
to TIC and for TIC to release pertinent payments to other parties for the purposes of processing my claim.
I certify that the information contained herein is true, complete and accurate and that each of the listed expenses was purchased and/or incurred in connection
with the medical treatment of the individual(s) named below. I acknowledge that the submission of false or incomplete information may result in the delay or
denial of this claim. In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning this claim, I acknowledge and agree that TIC may
investigate any information about me, my spouse and/or dependents pertaining to this claim, which may be used and disclosed to any relevant Third Party,
and where applicable my plan sponsor, for the purpose of investigating and preventing fraud and/or plan abuse.
If I receive payment from TIC in an amount that exceeds the benefit(s) to which I am entitled under the policy (the “overpayment amount”), then I acknowledge
and agree that: (a) I am indebted to TIC for such overpayment; (b) TIC has the right to recover the overpayment amount through any means available by law;
and (c) TIC will offset any benefits payable to me by the overpayment amount until TIC has recovered the overpayment amount in full.
I declare my statements above, including all other past and future statements made through personal or telephone interviews relating to my claim, to be true,
complete, current and accurate.
Insured’s Signature:
Date:
Insured’s Name (please print):
Policy #:
7T003CF-0313_rev
MM/DD/YYYY
Underwritten by Co-operators Life Insurance Company. Property risks underwritten by The Sovereign General Insurance Company.
CLAIM FORM – HOSPITAL & MEDICAL
SECTION 2: INSURED’S INFORMATION
Insured’s First Name:
Last Name:
Date of Birth:
MM/DD/YYYY
❑ Male
Phone #: (
)
Cell #: (
❑ Female
Policy #:
)
Fax #: (
)
Email:
Address:
City:
Province:
Departure Date:
MM/DD/YYYY
Return Date:
MM/DD/YYYY
Postal Code:
Destination:
SECTION 3: INSURED’S PHYSICIAN INFORMATION
Canadian family physician:
Street Address:
Province:
City:
Postal Code:
Phone #: (
)
Fax #: (
Pharmacy:
)
Phone #: (
)
SECTION 4: MEDICAL INFORMATION
1. What was the diagnosis?
MM/DD/YYYY
2. If your claim is due to sickness, when did symptoms first appear?
MM/DD/YYYY
Date of first treatment:
Treating Physician, Clinic, or Hospital:
Have you experienced this sickness or a similar problem before?
❑ Yes ❑ No
If ‘Yes’, when?
MM/DD/YYYY
Please provide the names of any medications
you were taking prior to visiting the doctor:
Do you have any chronic sickness or disease?
Date: M M / D D / Y Y Y Y
Diagnosis:
MM/DD/YYYY
Diagnosis:
Date:
❑ Yes ❑ No
If ‘Yes’, please provide date diagnosed and describe condition/diagnosis:
3. In the case of an injury, when, where and how did it happen? When:
MM/DD/YYYY
Where:
How:
If injury occurred on private property, please provide the following information:
Name of company insuring the property:
Property owner:
Phone # of insurance company: (
Policy #:
)
Claim # (if applicable):
4. If your claim relates to a motor vehicle accident, please provide the following information:
(if more than one vehicle was involved, include a separate sheet with the following information for each vehicle)
Name of company insuring the vehicle:
Vehicle owner:
Phone #: (
Policy #:
)
Claim # (if applicable):
SECTION 5: OUT OF POCKET EXPENSES (original receipts must be provided)
Expense type (for example: physician services, medications, meals, accommodation, taxi)
Date of service
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
1.
2.
3.
Amount billed
Amount you paid
$
$
$
$
$
$
Currency
Complete the following if another person made the payment for you and you want TIC to reimburse them directly.
I authorize TIC to make payment payable to
who has pre-paid my expenses.
Payment should be sent to Street Address:
City:
7T003CF-0313_rev
Province:
Postal Code:
Underwritten by Co-operators Life Insurance Company. Property risks underwritten by The Sovereign General Insurance Company.
CLAIM FORM – HOSPITAL & MEDICAL
SECTION 6: OTHER TRAVEL INSURANCE COVERAGE
Do you have any other travel or out-of-country medical insurance coverage?
❑ Yes
❑ No
If ‘Yes’, provide details below.
Plan
Name of Insurance Company
Group Policy #
Member ID#
Telephone
Your Employer
(
)
Your Spouse’s Employer
(
)
Your Parents’ Plan
(
)
Retiree Plan
(
)
Name of Spouse:
Spouse’s Date of Birth:
Do you have credit card insurance coverage for travel outside your province?
Name of issuing bank:
First 6 digits of credit card #:
MM/DD/YYYY
❑ Yes ❑ No
Expiry Date:
MM/YYYY
Name of Cardholder (please print):
Do you have travel insurance benefits available through any other source?
❑ Yes
❑ No
If ‘Yes’, provide details below.
Plan
Name of Insurance Company
Policy #
Telephone
(
)
(
)
(
)
(
)
(
)
SECTION 7: PROVINCIAL GOVERNMENT HEALTH INSURANCE (GHIP) AUTHORIZATION AND RELEASE
I agree that, pursuant to the terms of this policy and in respect of the applicable provincial health insurance legislation pertaining to freedom of information and
protection of privacy; and in consideration for any monies TIC may advance to me as a result of the issuance of this policy, I hereby irrevocably:
1. direct and authorize GHIP to make payment in respect of my claim for out-of-country health services to TIC directly and I hereby release GHIP, upon payment to
TIC, from any further claim or cause of action in connection therewith;
2. consent and authorize GHIP to directly collect information contained in the claim and source documents pursuant to the applicable freedom of information
and protection of privacy legislation and the applicable provincial health insurance legislation; and
3. consent to the disclosure by GHIP to TIC of such personal information as may be necessarily required for the processing of my claim for out-of-country health
services, including the details of any duplicate payment made directly to me or on my behalf.
Insured’s Signature:
Date:
MM/DD/YYYY
GHIP #:
(Government Health Insurance Plan #)
SECTION 8: DIRECTION AND AUTHORIZATION TO PHYSICIANS, HOSPITALS AND OTHER MEDICAL PROVIDERS
By signing this form, I hereby authorize and direct any physician, health care facility, treatment provider, plan administrator, any insurance company, reinsurer,
provincial health insurance plan, government department (collectively, “Third Party”) having medical or other relevant personal information regarding me, my spouse
and/or dependent to disclose, release, share and exchange information with TIC, its underwriter, plan administrator, agent or representative any and all such
information necessary for the purposes of determining my eligibility, assessing my application, investigating and confirming the accuracy and validity of my claim,
and administering or processing my claim. I am authorized to act on behalf of my dependants for these purposes. The authorization and direction I provided herein
shall be good and sufficient authority, and any copy of this completed form is as valid as the original. My consent and authorization shall remain valid for the
duration of my claim unless I revoke these in writing.
Insured’s Signature:
Date:
Send your completed forms
and original receipts to:
To check your claim status,
please call:
TIC Claims Department
2100 – 250 Yonge Street
Toronto, Ontario M5B 2L7
Toll-free Canada/USA 1-800-869-6747
Collect worldwide: 416-340-8809.
E-mail: [email protected]
7T003CF-0313_rev
MM/DD/YYYY
Print Form
Underwritten by Co-operators Life Insurance Company. Property risks underwritten by The Sovereign General Insurance Company.